DATE: 3/12/2015

ACCIDENT NOTIFICATION FORM

SIHCI / CICO

ACCIDENT NOTIFICATION REPORT

Notification N ;
1

Please fill in this form and immediately send it to the Administration Manager in case an accident occurs; with a copy to
Managing Director and Plant Manager.

Vehicle Make & ModelToyota hiluxDouble cabin. Reg. No. UAU 692 X
Company No.

Date: 13

/ 02/ 2016

Hour: 09

/ 50

pm

Place:.....BANA BANA BARRACKS..........................KM ......................................................................................

.................
Description

4
5

of

the

accident:

The driver of motor vehicle was trying to dodge a cow when he lost control of the vehicle and it overturned injuring
two people and killing one
Drivers Name: LI/MA

License / Permit No10462038/2/1

Employees ID NoNIL..

Date of Employment: ....

Injured Person(s)
Name(s) YUEN M/A. Description of the injured Person (s)
(CICO Workers / Third Party) LI M/A..
..
...
...
...
(If they are many, you can use extra sheet and you attach it to this form)
Witness(s)
a) Name:..Tel No
Remarks:
b) Name:...Tel No...
Remarks:.

c) Name: ...Tel No...

Remarks..
Police Report Attached
Drivers Statement Attached
Witnesss Report Attached
Drivers Permit Copy Attached

PROJECTMANAGERS NAME: .
DATE:..

SIGNATURE:

SIHCI /CICO
Date / Year:

INCIDENT REGISTER
Item

Date

Notification

Report

Revision

Description

Date

FTL

Legenda
Item

Project Code - Progressive Accident Number

Notification

Accident Notification Date

Report

Report date of issue

Revision Date

Revised report as per DQS/DP comments date of issue (if the case)

Classification

A, B or C

Type of Accident
FTL

Fatal Accident LTI

Lost Time Injury

CI

Commuting Injury

RTA

Road Traffic Accident

NM

Near Miss

DP

Damages to Properties

EI

Damages to Environment

Section of Work

Section of accident

Type of Accident

Classification

24. ANNEX B; ACCIDENT NOTIFICATION FORM

Occupational Health & Safety Management Plan
Page 54 of 58

LTI

RTA

CI

DP

Work
EI

NM

Section

Cause

Status O/C
(Open
Closed)

25. ANNEX C: INJURY MEDICAL REPORT

SIHCI/ CICO
MEDICAL INJURY REPORT

Please fill in this form and immediately send it to the Administration Manager in case an accident occurs; with a copy to
Managing Director and Plant Manager.

Details of the
Event :
Time: _

2
Date: /
3

Injury Location:

Details of the injured

person :
Designation:

Name:_
Department:_

ID No.:

Date of birth:_
4

Date of employment:

Nationality:
/

a) What Happened

/ Description
Gender:
of Male
the

injury:

Female

Age

b) Causes

Contact with

Plants

Hit against

Vehicles

Hit by

Tools

Fall at the same level

Materials / Substances

Pricked by

People / Animals

Crushed by

Machine parts

Fall from a height (>2mts)

Tanks and containers

Struck him/her self with

Handling

Lifting

Equipments
Fall from the same level

Others (Specify)

Burns / Fire
Run over
False movement
Vehicle / Equipment Accidents
Others (describe)
5
Abrasion, Scratch

Injury
Classification:
Hernia

Compression

Crushing
Amputation

Dislocation

Cuts /Laceration

Asphyxiation

Electrocution

Radiation

Animal / Insect bite

Inflammation

Post-traumatic stress

Burns

Infection

Dehydration

Bruising

Foreign body

Freezing

Page 55 of 58

Contusion
Concussion

Fracture

Multiple

Sprain

Other

(Specify)
Effects of Toxic Substances

Strain

Part of the body

injured:
LR
Ear

6
Head

Eye

LR

Face

Neck

Chest

Abdomen

Elbow L R

Wrist

LR

Hand

LR

Thigh L R

Knee

LR

Leg

LR

Foot

Spine

Shoulder

R
Arm

LR

Pelvis
Hip

LR

Fingers L R
3 4 5
LR

Toes 1 2

Other Observations by the medical personnel:

The Patient was treated

from:
st

nd

1 Clinic / Hospital

2 Clinic / Hospital

Name of medical facility

rd

Clinic / Hospital

Name ofthe
medical
facility
Describe
kind
of treatment given: Name of medical facility

Prognosis:

10
Fist Prognosis.
From;
To;
No. Days:
11

Multiple injuries

1 2 3 4 5

LR

Final prognosis

/_
/

/_
/

From;

/_

To;

Permanen t disability
/

Death
Yes No

No. Days:

If any Instructions relating to work, please describe:

26. ANNEX D: SAFETY HAZARD REPORT

SAFETY HAZARD REPORT
To:

From: Safety Department

Location:
Hazard Spotted:

Date:

Time:

Description of Situation:

Suggested measures:

Action before:

Safety Inspector:

Signature

Eventual comments from receiver:

Receiver for knowledge and receipt:

Signature

Measures Taken:

Closed date:
Safety Officer

Safety Officer:

Signature

Project Manager

ACCIDENT INVESTIGATION REPORT

SIHCI /CICO
UGANDA
DATE: / /
INCIDENT INVESTIGATION REPORT
PROJECT SITE;
1

Please fill in this form and immediately send it to the Administration Manager in case an accident occurs; with a copy to Man aging
Director and Plant Manager.

General Information about the incident.

- Location:
- Drivers Name:

Date:

Time

License / Permit No

- Date of Employment:

Employees ID No

Alcohol test Results

Description of the incident:

In the course of incident the following were damaged / injured:

People
Company Property
Environment
Others

Positive

Negative

None

Specify the Class of incident in relation to severity of damage or injury:

5

7
8

Class A (Slight)

List of People involved:

1. Name:
2. Name:
3. Name:

Class B (moderate)

Class C ( very Serious)

Employee No.
Employee No.
Employee No.

Task:
Task:
Task:

List of property (equipments , vehicles, plants etc) involved:

1.
2.
3.
Causes of the event:
Witness(s)
1. Name:
2. Name:
3. Name:

Corrective measures taken:

10

Other information if any:

11

Enclosures:
Police Report Attached
Drivers Statement Attached
Witnesss Report Attached
Drivers Permit Copy Attached

Employee No.
Employee No.
Employee No.

Task:
Task:_
Task:

12

Project Managers Name:

Signature:
Date: